research institute for compassionate economics

Hot lunches for some, medical exams for nobody, and normal health for all

Written by Dean Spears on October 23rd, 2011
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Last week Diane, Avinash, and I spent some time in a village in north Bihar. At the first glance, the village had some very useful public facilities – decent roads, subsidized food, and at least three schools. But, a little bit of conversation reminded us to look beyond the first glance. Diane already wrote about the subsidized ration shop dealer and his complete circumvention of the coupon system. Today, I’d like to tell about what we saw at a few schools.

We visited three. The first was a Sanskrit school, seemingly for younger children. When we got there, no classes were being held. Instead, all of the teachers were sitting around a table at a porch outside, where a smart-looking young man from the city was rapidly filling out papers.

It was health card day. Today all of the schools in the village were tasked with filling out a green, three-page health card, asking for detailed health information about each child. In principle, the data would feed into state administrative health records, and maybe would be used to identify children needing medical attention. The cards asked many detailed questions – from basics like height and weight to indicators of depression, attention disorder, and gynecological health.

On the back of the cards – to my delight – was a ten-step illustrated guide for properly hand-washing with soap. But the diagrammatic message would never make it into the children’s homes: the cards were being completed on the spot.

It turned out that the young man was a doctor, imported to complete the physical exams. He had found a way of folding the cards that allowed him to complete two of the pages (with large grids of conditions) almost at once. He wrote an N at the top of the page (for “normal,” he told me) and drew a long stroke through all of the boxes.

This innovation allowed an assembly line: first, a child would present himself before the doctor. One of the teachers would have already folded the card. The doctor got to work: a N, a line, an N, a line. The rest of the card was left blank. Another teacher took the card away, adding it to the completed pile. On to the next child, fifteen seconds flat. Twenty at the maximum. Boys and girls alike, all had normal gynecological development.

One father had brought a small girl to the school. He explained to us that he had heard that there was a doctor around today, and hoped she could get some medical treatment. By the time we had left, he hadn’t had any luck getting the doctor’s attention away from the cards.

The next school was a boys-only school. Here, too, there were green health cards, but there was no doctor. The teachers were filling out the cards themselves. [EDIT: Diane tells me that the doctor was scheduled to come there to fill out more of the cards later that week.] Some were sitting in the classroom with the children. At least one had moved his desk outside, where it was cooler and sunnier, leaving the kids inside to, among other things, hit one another with sticks.

But all was not lost at the boys’ school, because the school kitchen was preparing a mid-day meal. The cooks proudly showed the biggest pot of yellow dal (about a meter in diameter) I have ever seen, cooking over a fire in a cement room. [EDIT: Diane tells me that no actual dal was involved; the lunch featured Texturized Vegetable Protein (TVP)] The children would get to eat a hot cooked meal.

To my surprise, however, not all of the children would eat it: this was a relatively high-caste village, and apparently some high caste mothers would have sent their children with some food rather than let them eat out of the same pot as their low-caste classmates. This is a common pattern in India: richer or higher-ranking people opt-out of public services. They send their children to private schools; they buy water, rather than use the common pump; they take cars instead of public transportation; they buy generators or inverters for when the electricity goes out. One consequence may be that when something goes wrong with the public service (and something always goes wrong), the most powerful potential users do not complain: they have opted-out, potentially making the public service worse for everybody else.

Finally, we made our way to the girls’ school. Here, all of the male teachers were clustered on the main porch, watching another doctor complete the green health forms. This one apparently had no need to even visually inspect the children. The female teachers were in their classrooms, some were even teaching. We realized that, at all three schools, every female teacher we had seen had been in a classroom with the students; every male teacher we had seen had not been.

Unlike for their brothers across the village, for the girls there would be no mid-day meal. Nothing was being cooked. When we asked, somebody explained that there wasn’t enough money, or that the money for food had run out. We wondered who had decided, at what level in the system, that it would be acceptable to syphon off the money for the girls’ lunches, but not the boys.

As villages go, this was a relatively educated and socially cohesive and high-ranking one: many of the villagers belonged to high-ranking castes that are traditionally associated with education. Some theorists of local democracy might predict that it is exactly here where families would spontaneously come together to demand more out of their government. Yet, nobody seemed to be doing anything about medical exams that never examined the children, school teachers that often did not teach, or food that never made it to the girls.

This is perhaps understandable: if nothing else, like poor people worldwide, they had other things to do. It was nobody’s problem in particular. Would anything even change if they complained? Worse still, some of the best-off families may have “opted-out” of caring about these public services, finding their own solutions. But if this village was not holding government service providers accountable – as some development institutions and experts hope – is there much reason to think that the other villages in their district are?